|Year : 2019 | Volume
| Issue : 2 | Page : 89-98
Vascular access related complications with ipsilateral upper limb oedema in hemodialysis
RD Nagaraj1, Sarala Settipalli2, P Sandeep1, AY Lakshmi2, V Sivakumar1
1 Department of Nephrology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
2 Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
|Date of Web Publication||6-Jun-2019|
Dr. Sarala Settipalli
Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Background: Central vein-related obstruction is a growing problem in maintenance hemodialysis (MHD). Prior to central vein temporary access, failure to implement “fistula first policy” is an important contributor for this problem. It interferes with the outcomes in dialysis adding to mechanical vascular perturbations, resulting in limb, facial, and chest wall edema. Keeping them in view, we undertook this study on MHD patients, presented with central vein-related vascular access problems and ipsilateral upper limb edema, with the aim to investigate the vascular anatomical obstructive lesions causing the clinical syndrome and their management. Materials and Methods: This cross-sectional study included 25 patients of end-stage renal disease on MHD who manifested with vascular access dysfunction, presented with ipsilateral upper limb edema, and were the study subjects. All patients were evaluated with thorough clinical, laboratory, and computed tomographic (CT) angiography (CTAngio) studies to address the issues. Results: All patients had ipsilateral upper limb edema and 36% of them had in addition facial edema. Fifty percent had difficult cannulation with raising venous pressure during HD sessions and difficulty in securing hemostasis at the end of dialysis. CTAngio revealed central vein stenosis in 48%, peripheral stenosis in 20%, and combined central and peripheral stenosis in 32% patients. Cephalic arch involvement was noted in 16% patients. Depending on the patients preference, dialysis switched over to peritoneal dialysis in 24%, new vascular access was created in 20%, and balloon angioplasty in 16% during management. Conclusions: This study describes the central venous-related problems in MHD patients. We reiterate the importance of three early warning signs: high venous pressure, difficulty to achieve hemostasis at the end of dialysis, and ipsilateral limb, face, chest wall edema as the presage signs to suspect and exclude the underlying central vein obstructions. A continuum of management is discussed.
Keywords: Central venous access, computed tomographic angiography, upper limb edema
|How to cite this article:|
Nagaraj R D, Settipalli S, Sandeep P, Lakshmi A Y, Sivakumar V. Vascular access related complications with ipsilateral upper limb oedema in hemodialysis. Indian J Vasc Endovasc Surg 2019;6:89-98
|How to cite this URL:|
Nagaraj R D, Settipalli S, Sandeep P, Lakshmi A Y, Sivakumar V. Vascular access related complications with ipsilateral upper limb oedema in hemodialysis. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2020 Feb 22];6:89-98. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/89/259654
| Introduction|| |
The vascular access has been the Achilles heel in the successful patient management in maintenance hemodialysis (MHD). Patients with chronic kidney disease need a well-functioning vascular access to be initiated into HD. There are currently three main forms of HD vascular accesses: (1) the native arteriovenous fistula (AVF), (2) the polytetrafluoroethylene (PTFE) graft, and (3) cuffed/noncuffed double-lumen silicon catheter. The preferred accesses are native AVF, PTFE graft, and temporary catheters in the decreasing order. The temporary catheters should be avoided at all costs because of high incidence of thrombosis and infection.
The vascular access dysfunction is an important cause of morbidity and mortality in HD population. From the medicare data, it was estimated that the vascular access dysfunction is responsible for 20% of all hospitalizations in the HD population with significant financial implications. It is expected that central venous cannulation leads to intimal injury associated with focal endothelial denudation, increased smooth muscle, and vein wall thickening. The rapid blood flows associated with the HD catheters can create turbulence that accelerates endothelial proliferation eventually leading to thrombosis and stenosis.,
The cephalic arch is the term given to the final arch of the cephalic vein before it joins the axillary vein to form the subclavian vein. The arch has unique architecture: high concentration of valves, steep angulation, crosses multiple tissue planes bridging the superficial and deep venous systems and tethered to the rigid extravascular structures. When the anastomosis is created between the brachial artery and the cephalic vein, the flow within the cephalic vein is increased and the vessel begins to dilate. However, the tissues surrounding the cephalic vein preclude its expansion so that the cephalic vein narrows as it approaches its junction with the central veins. This sudden reduction in the circumference of a high flow pathway results in inflow–outflow mismatch potentiating turbulence and the increased shear stress associated with it. The turbulence is the likely primary etiological factor in contributing to the injury-induced hyperplasia.,, To provide HD in the absence of a permanent vascular access, temporary venous cannulation is mandatory. Placement of catheters in the central venous system can lead to the development of stenosis and thrombosis.
The etiology of central venous stenosis (CVS) remains complex and is related to a number of factors including the following: (a) mechanical injury from either repeated catheter insertion or continuous catheter movement inside the vein invoking endothelial damage, subsequent inflammation, intimal hyperplasia, and fibrosis; (b) catheter- or AVF-related changes in the flow dynamics leading to increased shear stress, platelet aggregation, and intimal hyperplasia; or (c) a combination of the previous two factors in the presence of patient-specific factors.,, The risk factors for the CVS quoted in different studies were female sex, subclavian insertions, more number of catheterizations per vein, and cumulative days of cannulation.,
Majority of the CVS occurs at the subclavian vein-cephalic vein junction. In 5% of patients, CVS can develop without any history of dialysis catheter or an earlier pacemaker insertion. Sometimes, an extensive encircling thrombus around a central venous catheter may result in a stuck catheter phenomenon when not removed timely.
Unlike in the developed world where MHD is in availability as a supportive management for end-stage renal disease (ESRD) patients across the different sections of population for five to six decades, in developing countries such as ours, provision of the same is gaining popularity during the last decade with the help of several governmental and private organizations. Hence, the understanding of vascular access-related problems is of recent origin and the literature is sparse.
Keeping these issues in view, this study was taken up to understand the causes, presentation, diagnosis, and management options in our group of patients in the given limitations of family's support, finances, and limited/nonavailability of endovascular and surgical facilities.
| Materials and Methods|| |
This was a cross-sectional, observational study performed from August 2013 to February 2016. There were a total of 233 patients of ESRD who were treated with MHD in our unit during this time. Of them, 25 patients who had vascular access dysfunction with ipsilateral limb edema were included in this study. All the patients were subjected to thorough clinical evaluation, routine hematological and biochemical workup, color Doppler study, and computed tomographic (CT) angiography (CTAngio). CTAngio was performed in a 128-slice Siemens Somatom CT scanner. It was done by injecting around 100–120 ml of 300% nonionic contrast intravenously at the rate of 5.0 ml/s through a peripherally placed intravenous (IV) cannula using the pressure injector. IV cannula is placed in the limb contralateral to the side where AVF is present or in the lower limb veins when bilateral upper limb veins were evaluated to avoid artifacts from the high density of the injected contrast material. The scan is acquired in arterial and venous phases including the limbs and neck vessels.
Postprocessing of the acquired data is done using three-dimensional reconstruction techniques such as MIP, MinIP, SSD, and MPR. The images are assessed regarding the status of the feeding artery, the fistulous site, and the draining veins including the central veins. The central veins include bilateral internal jugular vein (IJVs), subclavian veins, brachiocephalic veins, and superior vena cava. The presence of thrombosis and stenosis in the draining vein up to the insertion into the deep vein is considered as peripheral and presence of obstruction in the deep vein beyond the insertion of the draining vein is considered as central type.
If filling defect is noted within the vein and no contrast opacification is seen and vein is of normal caliber, it is designated as thrombosis with occlusion. If vein wall thickening is seen and/or lumen is narrowed in caliber and contrast opacification is seen within the vessel, it is taken as stenosis. By following this criteria, CTAngio data of 25 patients were classified into central and peripheral types or both central and peripheral. The presence of stenosis or thrombosis is also identified and the data are analyzed in clinical context. CTAngio study and the categorization were done by the same radiologist to avoid interobserver variation and personal bias. The evaluation was done in all the patients following a prior consent.
| Results|| |
During the study period, 25 patients of ESRD with various vascular access dysfunction and presenting with ipsilateral upper limb edema were included in this study. The mean age of the patients was 51.4 years (age range from 17 to 72 years). Male: female ratio was 18:7. The primary kidney disease was secondary to diabetes mellitus in eight of them and the rest were of nondiabetic etiology. The mean dialysis vintage in the patient group was 26.64 months (range being 3–68 months). Thirteen patients (52%) were on twice weekly maintenance dialysis and the rest 12 patients (48%) were on thrice weekly maintenance dialysis as per the patient's preference. The demographic, clinical presentation, imaging findings of vascular thrombosis/stenosis (central, peripheral, and combined central and peripheral), and management are tabulated separately in [Table 1].
|Table 1: Clinical details in patients with central venous related vascular access problems presenting with ipsilateral upper limb edema|
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Of the 25 patients, 11 (44%) had radiocephalic AVF (right side 5, left side 6), nine patients (36%) had brachiocephalic AVF (right side 3, left side 6), two patients (8%) had left brachiobasilic AVF, three patients (12%) had brachioaxillary graft (right side 2, left side 1) [Table 2]. All of them had at presentation ipsilateral limb edema [Figure 1].
|Figure 1: Edema of left half of face, dilated veins in the left half of chest, and swollen left upper limb with ipsilateral brachiocephalic fistula in a patient on maintenance hemodialysis|
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Of the 25 patients at the time of initiation of dialysis, 17 patients (68%) had temporary nontunneled catheters and eight patients (32%) had native AVF. Of the eight patients, four had radiocephalic AVF and the other four had brachiocephalic AVF. The site of first catheter insertion was in IJV on the right side in a majority of them. Only one patient had a history of subclavian catheter insertion. Thirteen patients (52%) had a history of catheter insertions at the same site. Nine (36%) had a history of multiple central vein catheter insertions at different sites.
On further analysis, we found the total nontunneled vein catheterizations were 40 in number for 21 patients, with male and female ratio being 16 (76%):5 (24%), suggestive of male predominance in our study. Of them, the right-sided IJV catheterization insertions were 32 (80%) and remaining were to be left IJV system 8 (20%). The mean insertion rate was 1.68 per patient. The mean catheter (tunneled and nontunneled) stay duration was 65.8 days per catheter insertion (14–560 days). The total duration of nontunneled catheter stay in CVS was 2120 days (14–196 days). Mean stay was 53 days. We found catheter-related bloodstream infections (CRBSI) in nine patients (36%). The total tunneled catheterizations were two in number for two patients, one being male and other being female; there was no incidence of CRBSI in relation to tunneled catheters [Table 3].
|Table 3: Showing details of catheter insertions, duration of catheter stay and incidence of CRBSI|
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All the patients had ipsilateral limb edema and nine (36%) had in addition facial edema along with limb edema. In 13 patients (52%), difficulty was encountered in cannulation. Sixteen patients (64%) had rise in venous pressures during HD. Eleven patients (44%) had difficulty in securing hemostasis at the end of dialysis procedure.
Basing on the CTAngio findings, we observed central stenosis or thrombosis [Figure 2] in 12 (48%) patients, peripheral stenosis or thrombosis [Figure 3] in five (20%) patients and combined central and peripheral stenosis or thrombosis [Figure 4] in eight patients (32%) [Table 4].
|Figure 2: Brachiocephalic fistula with thrombosis, total occlusion of right internal jugular vein, right brachiocephalic vein, and stenosis in distal right subclavian vein with multiple collaterals in contrast enhanced multislice computed tomographic angiogram with diagrammatic representation in addition|
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|Figure 3: Right brachioaxillary fistula with venous graft showing narrowing of the graft near the arterial and venous anastomosis. Narrowing of the axillary vein also noted near the anastomosis of the venous end of the graft|
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|Figure 4: Status postleft brachiocephalic fistula showing thrombosis of the mid cephalic vein|
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Among the patients who had peripheral stenosis or thrombosis (13 patients), the site of involvement was juxta anastomotic in two (15%), midvein in three (23%) and proximal involvement in eight (62%) patients. Cephalic arch was involved in four (16%) patients [Figure 5]. In one patient, we found extensive encircling thrombus around a central venous catheter which probably would have resulted in a stuck catheter phenomenon had it not been removed timely [Figure 6].
|Figure 5: Status postleft brachiocephalic fistula showing stenosis in the distal part of cephalic vein in the deltopectoral groove where the cephalic vein terminates in to the deep vein|
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|Figure 6: Status postright brachiocephalic fistula showing thrombus in right internal jugular vein, right brachiocephalic vein. The jugular catheter is struck with in the venous thrombus|
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| Discussion|| |
It is said that history repeats itself and the same appears to be true with vascular access problems, as what being said in Occident yesterday is occurring in Orient today. The vascular access problems are expected to increase in view of increasing availability and acceptability of the MHD support for ESRD patients in developing countries including India in recent years. Hence, it may be prudent that all central venous catheterizations be done under ultrasonographic guidance to minimize vascular trauma so as to reduce the vascular access-related problems.
In this study, we analyzed the data on 25 patients of ESRD on MHD presented with vascular access-related problems and ipsilateral upper limb edema taking the help of CTAngio. In the management, six patients (24%) were switched over to peritoneal dialysis and the remaining 19 (76%) patients were maintained on HD. In the HD group, bridge temporary vascular access was secured in six patients (24%), a functioning new vascular access was possible in five patients (20%) and dialysis was continued with the same vascular access despite technical difficulties due to patient-related reasons in 12 patients (48%). Of the four patients (16%) who underwent balloon angioplasty, the success was temporary in three patients, and in the remaining one patient, it was successful for utility in dialysis till the end of study time. We could not asses the response of angioplasty in relation to vessel wall elasticity.
In developing countries, financial constraints and limited technical expertise make the vascular access problems difficult for repair and management. Hence, many opt for a switch over to CAPD program. Vascular access problems are important because of their impact on mortality and morbidity in this group of patients. Hence, there is an impending need for specially trained team in nephrology practice to address this precarious issue in providing remedial measures to make available a functional AV access as far as possible or placement of a bridge access to tide over the crisis in sustaining life as is practiced in the developed world.
| Conclusions|| |
Patients with problems during MHD such as high venous pressures, difficulty to obtain hemostasis at the termination of dialysis, and progressive ipsilateral upper limb edema need thorough clinical and radiological vascular evaluation to exclude stenosis and/or thrombosis in the venous system, to discern, anatomical, functional significance and management assessment. Prior central venous catheterization remains an important predisposing factor for vascular access dysfunction in our patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4]